Does an outreaching stepped care program reduce depressive symptoms in community-dwelling older adults? A randomized implementation trial

The contribution of primary care practitioners to interventions reducing loneliness and social isolation in older people-An integrative review

BACKGROUND

Social connection is a fundamental human need. Its absence can lead to loneliness and social isolation, adversely impacting health and well-being. Given their regular contact and trusted relationships with older people, practitioners delivering community-based primary care are well-positioned to address this issue. However, their contribution to addressing loneliness and social isolation is unclear.

AIM

This integrative review explores the contribution of the primary care workforce to interventions aimed at reducing loneliness and social isolation in community-dwelling older people.

METHOD

Using an integrative review method, Scopus, Web of Science, CINAHL and PubMed were searched for original research published between 2000 and 2022. Fourteen papers reporting 13 primary studies were appraised for methodological quality and included in the review. Data were extracted into a summary table and analysed using thematic analysis.

RESULTS

Included studies came from over six countries. Internationally, primary care services have diverse structures, funding and workforces influencing their response to loneliness and social isolation. All but one intervention was multi-component, with ten studies including a group-based activity and three providing primarily individual-level activities. Only six studies reported reductions in loneliness following the intervention. Three themes were identified: characteristics of interventions; implementation context, barriers and facilitators; and differing contributions of primary care practitioners in addressing loneliness and social isolation of older people.

CONCLUSION

There is increasing demand and scope for primary care practitioners to assist lonely and socially isolated older people. It is important to understand how to equip and incentivise these practitioners to routinely identify, assess and respond to lonely and socially isolated older people despite varying implementation contexts. There is a need for further research that explores how the primary care team can be better utilised to deliver effective interventions that reduce the health impacts of loneliness and social isolation.

Personalized care planning and shared decision making in collaborative care programs for depression and anxiety disorders: A systematic review

BACKGROUND

Collaborative care is an evidence-based approach to improving outcomes for common mental disorders in primary care. Efforts are underway to broadly implement the collaborative care model, yet the extent to which this model promotes person-centered mental health care has been little studied. The aim of this study was to describe practices related to two patient and family engagement strategies-personalized care planning and shared decision making-within collaborative care programs for depression and anxiety disorders in primary care.

METHODS

We conducted an update of a 2012 Cochrane review, which involved searches in Cochrane CCDAN and CINAHL databases, complemented by additional database, trial registry, and cluster searches. We included programs evaluated in a clinical trials targeting adults or youth diagnosed with depressive or anxiety disorders, as well as sibling reports related to these trials. Pairs of reviewers working independently selected the studies and data extraction for engagement strategies was guided by a codebook. We used narrative synthesis to report on findings.

RESULTS

In total, 150 collaborative care programs were analyzed. The synthesis showed that personalized care planning or shared decision making were practiced in fewer than half of programs. Practices related to personalized care planning, and to a lesser extent shared decision making, involved multiple members of the collaborative care team, with care managers playing a pivotal role in supporting patient and family engagement. Opportunities for quality improvement were identified, including fostering greater patient involvement in collaborative goal setting and integrating training and decision aids to promote shared decision making.

CONCLUSION

This review suggests that personalized care planning and shared decision making could be more fully integrated within collaborative care programs for depression and anxiety disorders. Their absence in some programs is a missed opportunity to spread person-centered mental health practices in primary care.

Web-based exercise interventions for patients with depressive and anxiety disorders: a systematic review of randomized controlled trials

Objective:

The number of people suffering from depression and/or anxiety has increased steadily due to the coronavirus disease 2019 (COVID-19) pandemic. In this context, web-based exercise interventions have emerged as a potential treatment strategy. The objective of this study was to synthetize evidence from randomized controlled trials regarding the effects of web-based exercise interventions on patients with depressive and/or anxiety disorders.

Methods:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Six databases were searched (Cochrane Library, EBSCO, PubMed, SciELO, Scopus, and Web of Science), and eligible articles were identified according to a PICOS inclusion-exclusion approach (participants with depressive or anxiety disorders; web-based exercise interventions; active or passive control group; assessment of changes in depressive or anxiety disorders; randomized design). Primary outcomes were depressive and/or anxiety symptoms. The quality of evidence was assessed with Grading of Recommendations Assessment, Development, and Evaluation.

Results:

Of 7,846 search results, three studies met the inclusion criteria (172 participants between 18 and 65 years of age, 95.9% women). The web-based exercise interventions lasted 8-12 weeks and involved endurance training, yoga, or combined endurance and strength training. The comparators involved non-exercise controls or active controls. Compliance rates were low. Web-based exercise interventions were not superior to controls regarding anxiety symptoms, and only one study found benefits for depressive symptoms (p ≤ 0.05). The quality of the cumulative evidence was low.

Conclusion:

The available data regarding the effects of web-based exercise interventions on depression and/or anxiety symptoms is scarce, the risk of bias is high, and the quality of the cumulative results is low. Currently, no clear recommendations can be provided.

Registration number:

PROSPERO CRD42021225938.

Stepped care for the treatment of depression: a systematic review and meta-analysis

BACKGROUND

The Stepped Care Model (SCM) proposes a sequential approach in the treatment of depression, applying interventions of increasing intensity according to the level of severity of the individual.

METHODS

A systematic review was carried out until January 2020 in eight electronic databases. We included randomized (RCT) and non-randomized controlled trials comparing the SCM to usual non-sequential care.

RESULTS

Eighteen RCT with patients with confirmed or probable depression diagnosis were included. Meta-analyses yielded high heterogeneity, and subgroup analyses showed significant effects of the SCM only in studies with baseline moderately severe symptoms on average, compared to samples with mild/moderate depression. In the former subgroup, effects at 3-6 and 9-12 months were small for symptoms' reduction (g = -0.33, 95%CI: -0.55, -0.17 and -0.34, 95%CI: -0.53, -0.16) and moderate-to-strong in response and remission (Risk Ratios between 1.70-1.90). Overall, a significant benefit on quality of life was also observed (6 months: g = 0.31, 95%CI: 0.12, 0.49; 12 months: g = 0.18, 95%CI: 0.06, 0.31). More patients in the SCM groups were prescribed antidepressants at 6 months (RR = 1.31, 95%CI: 1.09, 1.57; I² = 87%).

LIMITATIONS

The search does not guarantee the identification of all the relevant literature. Most included studies show uncertain or high risk of bias.

CONCLUSIONS

The SCM seems to outperform usual care in populations with at least moderately severe symptoms on average. Results show high heterogeneity and future research should explore its sources.

Cost-effectiveness of a stepped care program to prevent depression among primary care patients with diabetes mellitus type 2 and/or coronary heart disease and subthreshold depression in comparison with usual care

BACKGROUND

Patients with diabetes mellitus type 2 (DM2) and/or coronary heart disease (CHD) are at high risk to develop major depression. Preventing incident major depression may be an important tool in reducing the personal and societal burden of depression. The aim of the current study was to assess the cost-effectiveness of a stepped care program to prevent major depression (Step-Dep) in diabetes mellitus type 2 and/or coronary heart disease patients with subthreshold depression in comparison with usual care.

METHODS

An economic evaluation with 12 months follow-up was conducted alongside a pragmatic cluster-randomized controlled trial from a societal perspective. Participants received care as usual (n = 140) or Step-Dep (n = 96) which consisted of four sequential treatment steps: watchful waiting, guided self-help, problem solving treatment and referral to a general practitioner. Primary outcomes were quality-adjusted life years (QALYs) and cumulative incidence of major depression. Costs were measured every 3 months. Missing data was imputed using multiple imputation. Uncertainty around cost-effectiveness outcomes was estimated using bootstrapping and presented in cost-effectiveness planes and acceptability curves.

RESULTS

There were no significant differences in QALYs or depression incidence between treatment groups. Secondary care costs (mean difference €1644, 95% CI €344; €3370) and informal care costs (mean difference €1930, 95% CI €528; €4089) were significantly higher in the Step-Dep group than in the usual care group. The difference in total societal costs (€1001, 95% CI €-3975; €6409) was not statistically significant. The probability of the Step-Dep intervention being cost-effective was low, with a maximum of 0.41 at a ceiling ratio of €30,000 per QALY gained and 0.32 at a ceiling ratio of €0 per prevented case of major depression.

CONCLUSIONS

The Step-Dep intervention is not cost-effective compared to usual care in a population of patients with DM2/CHD and subthreshold depression. Therefore, widespread implementation cannot be recommended.

TRIAL REGISTRATION

The trial was registered in the Netherlands Trial Register ( NTR3715 ).

Management of comorbid mental and somatic disorders in stepped care approaches in primary care: a systematic review

BACKGROUND

Stepped care models comprise a graded treatment intensity and a systematic monitoring. For an effective implementation, stepped care models have to account for the high rates of mental and somatic comorbidity in primary care.

OBJECTIVES

The aim of the systematic review was to take stock of whether present stepped care models take comorbidities into consideration. A further aim was to give an overview on treatment components and involved health care professionals.

METHODS

A systematic literature search was performed using the databases PubMed, PsycINFO, Cochrane Library and Web of Science. Selection criteria were a randomized controlled trial of a primary-care-based stepped care intervention, adult samples, publication between 2000 and 2017 and English or German language.

RESULTS

Of 1009 search results, 39 studies were eligible. One-third of the trials were conceived for depressive disorders only, one-third for depression and further somatic and/or mental comorbidity and one-third for conditions other than depression. In 39% of the studies comorbidities were explicitly integrated in treatment, mainly via transdiagnostic self-management support, interprofessional collaboration and digital approaches for treatment, monitoring and communication. Most care teams were composed of a primary care physician, a care manager and a psychiatrist and/or psychologist. Due to the heterogeneity of the addressed disorders, no meta-analysis was performed.

CONCLUSIONS

Several stepped care models in primary care already account for comorbidities, with depression being the predominant target disorder. To determine their efficacy, the identified strategies to account for comorbidities should be investigated within stepped care models for a broader range of disorders.

Patients' and practice nurses' perceptions of depression in patients with type 2 diabetes and/or coronary heart disease screened for subthreshold depression

BACKGROUND

Comorbid depression is common in patients with type 2 diabetes (DM2) and/or coronary heart disease (CHD) and is associated with poor quality of life and adverse health outcomes. However, little is known about patients' and practice nurses' (PNs) perceptions of depression. Tailoring care to these perceptions may affect depression detection and patient engagement with treatment and prevention programs. This study aimed to explore patients' and PNs' perceptions of depression in patients with DM2/CHD screened for subthreshold depression.

METHODS

A qualitative study was conducted as part of a Dutch stepped-care prevention project. Using a purposive sampling strategy, data were collected through semi-structured interviews with 15 patients and 9 PNs. After consent, all interviews were recorded, transcribed verbatim and analyzed independently by two researchers with Atlas.ti.5.7.1 software. The patient and PN datasets were inspected for commonalities using a constant comparative method, from which a final thematic framework was generated.

RESULTS

Main themes were: illness perception, need for care and causes of depression. Patients generally considered themselves at least mildly depressed, but perceived severity levels were not always congruent with Patient Health Questionnaire 9 scores at inclusion. Initially recognizing or naming their mental state as a (subthreshold) depression was difficult for some. Having trouble sleeping was frequently experienced as the most burdensome symptom. Most experienced a need for care; psycho-educational advice and talking therapy were preferred. Perceived symptom severity corresponded with perceived need for care, but did not necessarily match help-seeking behaviour. Main named barriers to help-seeking were experienced stigma and lack of awareness of depression and mental health care possibilities. PNs frequently perceived patients as not depressed and with minimal need for specific care except for attention. Participants pointed to a mix of causes of depression, most related to negative life events and circumstances and perceived indirect links with DM2/CHD.

CONCLUSION

Data of the interviewed patients and PNs suggest that they have different perceptions about (subthreshold) depressive illness and the need for care, although views on its causes seem to overlap more.

Effectiveness of a multifactorial intervention for dizziness in older people in primary care: A cluster randomised controlled trial

OBJECTIVES

Dizziness is common in older people. Physicians are often unable to identify a specific cause for dizziness in older people, even after an extensive diagnostic work-up. A prognosis-oriented approach, i.e. treating modifiable risk factors for an unfavourable course of dizziness, may reduce dizziness-related impairment in older people in primary care.

DESIGN

Cluster randomized controlled trial.

SETTING

45 primary care practices in The Netherlands.

PARTICIPANTS

168 participants aged ≥65y who consulted their general practitioner for dizziness and experienced significant dizziness-related impairment (Dizziness Handicap Inventory (DHI) ≥30). Participants were part of to the intervention group (n = 83) or control group (n = 85), depending on whether they were enlisted in an intervention practice or in a control practice.

INTERVENTIONS

The multifactorial intervention consisted of: medication adjustment in case of ≥3 prescribed fall-risk-increasing drugs (FRIDs) and/or stepped mental health care in case of anxiety disorder and/or depression and/or exercise therapy in case of impaired functional mobility. The intervention was compared to usual care.

OUTCOME MEASURES

The primary outcome was dizziness-related impairment. Secondary outcomes were quality of life (QoL), dizziness frequency, fall frequency, anxiety and depression, use of FRIDs.

RESULTS

Intention-to-treat analysis showed no significant intervention effect on dizziness-related impairment (DHI score difference -0.69 [95% CI -5.66;4.28]; p = 0.79). The intervention proved effective in reducing the number of FRIDs (FRID difference -0.48 [95% CI -0.89;-0.06]; p = 0.02). No significant intervention effects were found on other secondary outcomes. The uptake of and adherence to the interventions was significantly lower in patients eligible for ≥2 interventions compared to patients eligible for one intervention (p<0.001).

CONCLUSIONS

The multifactorial intervention for dizziness in older patients showed no significant intervention effect on most outcomes and adherence to the multifactorial intervention was low. Although multifactorial treatment for older dizzy people seems promising in theory, we question its feasibility in daily practice. Future research could focus on a sequential treatment for dizziness, e.g. measuring effectiveness of various evidence-based therapies in a stepwise approach.

Effectiveness of a stepped-care intervention to prevent major depression in patients with type 2 diabetes mellitus and/or coronary heart disease and subthreshold depression: A pragmatic cluster randomized controlled trial

Purpose

Given the public health significance of poorly treatable co-morbid major depressive disorders (MDD) among patients with type 2 diabetes mellitus (DM2) and coronary heart disease (CHD), we need to investigate whether strategies to prevent the development of major depression could reduce its burden of disease. We therefore evaluated the effectiveness of a stepped-care program for subthreshold depression in comparison with usual care in patients with DM2 and/or CHD.

Methods

A cluster randomized controlled trial, with 27 primary care centers serving as clusters. A total of 236 DM2 and/or CHD patients with subthreshold depression (nine item Patient Health Questionnaire (PHQ-9) score ≥ 6, no current MDD according to DSM-IV criteria) were allocated to the intervention group (N = 96) or usual care group (n = 140). The stepped-care program was delivered by trained practice nurses during one year and consisted of four sequential treatment steps: watchful waiting, guided self-help, problem solving treatment and referral to the general practitioner. The primary outcome was the 12-month cumulative incidence of MDD as measured with the Mini International Neuropsychiatric Interview (MINI). Secondary outcomes included severity of depression (measured by PHQ-9) at 3, 6, 9 and 12 months.

Results

Of 236 patients (mean age, 67,5 (SD 10) years; 54.7% men), 210 (89%) completed the MINI at 12 months. The cumulative incidence of MDD was 9 of 89 (10.1%) participants in the intervention group and 12 of 121 (9.9%) participants in the usual care group. We found no statistically significant overall effect of the intervention (OR = 1.21; 95% confidence interval (0.12 to 12.41)) and there were no statistically significant differences in the course or severity of depressive symptoms between the two groups.

Conclusions

This study suggest that Step-Dep was not more effective in preventing MDD than usual care in a primary care population with DM2 and/or CHD and subthreshold depression.

Process evaluation of a stepped-care program to prevent depression in primary care: patients' and practice nurses' experiences

Background

Depression is common in patients with diabetes type 2 (DM2) and/or coronary heart disease (CHD), with high personal and societal burden and may even be preventable. Recently, a cluster randomized trial of stepped care to prevent depression among patients with DM2 and/or CHD and subthreshold depression in Dutch primary care (Step-Dep) versus usual care showed no effectiveness. This paper presents its process evaluation, exploring in-depth experiences from a patient and practice nurse perspective to further understand the results.

Methods

A qualitative study was conducted. Using a purposive sampling strategy, data were collected through semi-structured interviews with 24 participants (15 patients and nine practice nurses). All interviews were audiotaped and transcribed verbatim. Atlas.ti 5.7.1 software was used for coding and structuring of themes. A thematic analysis of the data was performed.

Results

The process evaluation showed, even through a negative trial, that Step-Dep was perceived as valuable by both patients and practice nurses; perceived effectiveness on improving depressive symptoms varied greatly, but most felt that it had been beneficial for patients’ well-being. Facilitators were: increased awareness of mental health problems in chronic disease management and improved accessibility and decreased experienced stigma of receiving mental health care. The Patient Health Questionnaire 9 (PHQ-9), used to determine depression severity, functioned as a useful starting point for the conversation on mental health and patients gained more insight into their mental health by regularly filling out the PHQ-9. However, patients and practice nurses did not widely support its use for monitoring depressive symptoms or making treatment decisions. Monitoring mental health was deemed important in chronically ill patients by both patients and practice nurses and was suggested to start at the time of diagnosis of a chronic disease. Appointed barriers were that patients were primarily motivated to participate in scientific research rather than their intrinsic need to improve depressive symptoms. Additionally, various practice nurses preferred offering individually based therapy over pre-determined interventions in a protocolled sequence and somatic practice nurses expressed a lack of competence to recognise and treat mental health problems.

Conclusion

This study demonstrates both the benefits and unique demands of programs such as Step-Dep. The appointed facilitators and barriers could guide the development of future studies aiming to prevent depression in similar patient groups.